Download Polypharmacy, Adverse Drug Reactions, and Geriatric

Polypharmacy, Adverse
Drug Reactions, and
Geriatric Syndromes
Bhavik M. Shah, PharmD, BCPS*, Emily R. Hajjar, PharmD, BCPS, BCACP, CGP
KEYWORDS
• Polypharmacy • Elderly • Geriatric syndromes
• Adverse drug reactions
The older population, composed of adults aged 65 years or older, is the fastest
growing segment of the United States population. The Administration of Aging of the
United States Department of Health and Human Services reported that there were
approximately 40 million older adults in 2009, an increase of 12.5% from 1999. The
Administration projects the greatest increases to the older population to occur over
the next two decades as the first baby boomers reach the age of 65 in 2011. By 2030,
there will be approximately 72 million older adults.1 Chronic diseases are prevalent
among the older population; about 80% of older adults have at least one chronic
condition, and about half have at least two.2 These chronic conditions, which include
heart disease, hypertension, diabetes, arthritis, and cancer, often require multiple
medications for optimal management.
Although the use of multiple medications is widely referred to as polypharmacy, no
consensus exists on what number should define the term. In the literature, polypharmacy has been arbitrarily defined as taking at least two to nine medications
concurrently.3–7 This definition is controversial because polypharmacy may be
appropriate to treat a patient with multiple comorbid conditions. This appropriateness
is especially true for disease states such as chronic heart failure and diabetes, which
require multiple drug therapies as directed by disease state guidelines. For example,
a patient with Class IV New York Heart Association heart failure may be prescribed a
loop diuretic, an aldosterone inhibiting diuretic, a ␤-blocker, an angiotensin-converting enzyme inhibitor, digoxin to treat the heart failure, and other medications for any
other comorbid condition. Excessive polypharmacy is another type of polypharmacy
that is defined by medication count and generally uses cut points of 10 or more
B. Shah has no relationships to disclose.
E. Hajjar is a consultant for Prime Therapeutics.
Jefferson School of Pharmacy, Thomas Jefferson University, 130 South 9th Street, Suite 1540,
Philadelphia, PA 19107, USA
* Corresponding author.
E-mail address: [email protected]
Clin Geriatr Med 28 (2012) 173–186
doi:10.1016/j.cger.2012.01.002
geriatric.theclinics.com
0749-0690/12/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
174
Shah & Hajjar
medications. This definition is becoming increasingly studied as the population
continues to age and use more medications.
Alternately, polypharmacy has also been defined as taking at least one medication
that is not clinically indicated. This indication-based definition is argued to be more
practical and appropriate because it is independent of the multiple medications
necessary to treat the multiple comorbidities elderly patients are likely to have.7 This
definition necessitates a medication review and takes medication appropriateness
into account. Those that lack an indication or effectiveness or are determined to be a
therapeutic duplication are considered as polypharmacy or unnecessary medications.
An example would be a patient started on a proton pump inhibitor while an inpatient
for stress ulcer prophylaxis. If the medication is continued on an outpatient basis, this
medication would be considered unnecessary because there is no longer an
indication for the medication.
EPIDEMIOLOGY
Prevalence of Polypharmacy Defined by Medication Count
Overall medication use has increased recently. According to IMS Health data, the
number of prescriptions filled in 2010 was about 4 billion.8 Although making up about
13% of the US population, older adults filled one-third of all prescriptions and 40% of
nonprescription medications.9 The average older adult filled 31 prescriptions per year
in 2009, twice as many as all other age groups combined.10 Similar disproportionate
use has been reported in Canada and the United Kingdom.11,12
The prevalence of polypharmacy reported in the literature, ranging from 5% to
78%, varies because of the different definitions used and samples studied.7 Furthermore, the reported average number of prescriptions taken daily by ambulatory elderly
patients ranges between two and nine medications.13 Polypharmacy is more common in women, and its prevalence increases with advancing age.7 A large national
survey of prescription and nonprescription medication use in ambulatory adults found
that 57% of women aged 65 years or older took at least five medications, and 12%
took at least 10 medications.14 A European study of ambulatory older adults reported
a similar prevalence rate; 51% of elderly patients took at least six prescription and
nonprescription medications per day.15
Nobili and colleagues16 reported the rate of polypharmacy among hospitalized Italian
elderly patients of 52% with a mean number of 4.9 medications (N ⫽ 1332, mean age
79.4 years) upon admission; the rate of polypharmacy increased to 67% upon discharge
with a mean number of 6.0 medications.16 Schuler and colleagues17 reported a
polypharmacy rate of 58% upon admission in Austrian hospitals, with a mean number of
7.5 medications (N ⫽ 543, median age 82 years). In the United States, about half of elderly
patients admitted to hospitals take seven or more medications.18
A large national study of 13,507 nursing home residents showed a polypharmacy
rate of 40%. Polypharmacy was defined as at least nine medications, a higher
threshold compared with other studies in ambulatory or hospitalized settings.19 Data
on the prevalence rate in assisted living facilities is more limited. However, one study
of 2014 residents, the majority of whom were 85 years or older, in 193 assisted living
facilities reported a mean of 5.8 medications.20
Prevalence of Polypharmacy Defined as Unnecessary Drug Use
Medication use that is not clinically warranted is another definition of polypharmacy.7
Lipton and colleagues21 found that 60% of 236 ambulatory elderly patients aged 65
years or older were taking medications that lacked an indication or were suboptimal.
In a study of 196 elderly veteran patients, Steinman and colleagues22 evaluated
Polypharmacy, Reactions, Geriatric Syndromes
unnecessary medications by using the Medication Appropriateness Index (MAI),
defined as medications with no indication, lack of effectiveness, or therapeutic
duplication. They reported that 57% of patients were taking at least one unnecessary
medication. Using the MAI criteria for unnecessary medication, Schmader and
colleagues23 found that a mean number of 0.65 unnecessary medications were taken in
a study of 834 frail elderly veterans. Additionally, a study of 384 hospitalized frail elderly
veterans found that 44% of patients were discharged with at least one unnecessary
medication, as defined by the MAI.24 A majority of these patients (75%) had at least one
unnecessary medication prior to hospital admission. The most common reason was a
lack of indication (33%). Hanlon and colleagues25 reported similar findings; lack of
indication was the most common reason for unnecessary medications in a study of 397
hospitalized elderly veterans. Common unnecessary medications include gastrointestinal, central nervous system, and therapeutic nutrient/mineral agents.24
Most Common Medications
Kaufman and colleagues14 reported in 2002 that the most common prescription
medications among ambulatory older patients were conjugated estrogens, levothyroxine, hydrochlorothiazide, atorvastatin, and lisinopril. A study of ambulatory Medicare patients revealed that the most common drug classes prescribed in a 1-year
period were cardiovascular agents, antibiotics, diuretics, analgesics, antihyperlipidemics, and gastrointestinal agents.26 This result is to be expected because the
drugs reflect the common conditions that occur in community-dwelling elders. The
most common nonprescription medications consumed by older adults were analgesics (aspirin, acetaminophen, and ibuprofen), cough and cold medications (diphenhydramine and pseudoephedrine), vitamins and minerals (multivitamins, vitamins E
and C, calcium), and herbal products (ginseng, Ginkgo biloba extract).14 Other
nonprescription medications commonly used by elderly patients include antacids and
laxatives.27 A survey of institutionalized older adults found that the most common
medications were gastrointestinal agents, central nervous system agents (antidepressants, antipsychotics, antimanics), and analgesics (opioids and nonopioids).19
CONSEQUENCES OF POLYPHARMACY
There are many consequences of polypharmacy. Aside from increased direct drug
costs, patients are at higher risk for adverse drug reactions, drug interactions,
nonadherence, diminished functional status, and various geriatric syndromes.
Adverse Drug Reactions
The number of adverse drug reactions (ADRs) for all age groups has increased over
recent years, with an estimated 4.3 million ADR-related health care visits in 2005.28
Age 65 years or older and polypharmacy were significant risk factors for ADR-related
visits. ADRs occur in up to 35% of outpatients and 44% of hospitalized elderly
patients and account for approximately 10% of emergency room visits.29,30 Polypharmacy increases the risk of ADRs from 13% (two medications) to 58% (five
drugs).31 Seven or more medications further increases the risk of ADRs to 82%.31 The
most common drug classes associated with ADRs were cardiovascular drugs,
diuretics, anticoagulants, nonsteroidal antiinflammatory drugs, antibiotics, and hypoglycemics.26,30 These medications are prescribed for common conditions, and
providers should be aware of the risks for each medication class.
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Drug Interactions
The elderly are at high risk for drug interactions due to polypharmacy, comorbidities,
and decreased nutritional status, which may affect the pharmacokinetic and pharmacodynamic properties of medications.32 Potential drug-drug interactions are
common. In a prospective, randomized controlled longitudinal multicenter European
study of 1601 community-dwelling elderly adults, 46% of patients had a potential
drug-drug interaction.33 This result is consistent with other studies that report the
prevalence of potential drug-drug interactions between 35% and 60% in elderly
patients.29 The risk of drug-drug interactions increases with the number of drugs and
can approach 100% with eight or more medications.34 In elderly patients, drug-drug
interactions are a common reason for preventable adverse drug reactions and
hospitalizations related to drug toxicity.26,35
The prevalence of drug-disease interactions is reported to be 15% to 40% in frail
elderly patients.36,37 The investigators noted the most common interactions were
aspirin and peptic ulcer disease, calcium channel blockers and heart failure, and
␤-blockers and diabetes. The risk of drug-disease interactions has been shown to
increase as the number of drugs as well as the number of comorbidities increase.37
Risk of drug-disease interactions are of concern because few patients suffer from just
one chronic condition.
The prevalence rates should be interpreted cautiously, because they may be
overestimated due to how interactions and their clinical importance are defined.32
Additionally, many of the studies evaluated potential interactions, which may not be
clinically relevant.30 Nevertheless, the elderly are at risk for drug interactions. These
interactions are significant because they may decrease the efficacy or increase the risk of
toxicity of a drug. As a result, the prescriber may change the dose or add more
medications, further increasing the risk for other interactions and side effects.
Nonadherence
Complex medication regimens related to polypharmacy can lead to nonadherence in
the elderly.13 Studies in community-dwelling elderly adults have reported medication
adherence rates between 43% and 95%.38 The variability can be attributed to
different definitions for adherence, population characteristics, and how adherence
was measured. The number of medications has been shown to be a stronger
predictor of nonadherence than advancing age, with higher rates of nonadherence as
the number of medications increases.39,40 Nonadherence can lead to serious sequelae including disease progression, treatment failure, hospitalization, and adverse
drug events.40
Diminished Activities of Daily Living and Instrumental Activities of Daily Living
Polypharmacy has also been associated with functional decline in older patients. In a
prospective study of over 600 community-dwelling elderly, increased prescription
medication use was associated with decreased physical functioning and decreased
ability to carry out instrumental activities of daily living (IADLs) after controlling for age,
education, health, number of conditions, and baseline functional status.41 Another
cross-sectional study based on the Women’s Health and Aging Study found that the
use of five or more medications resulted in diminished ability to perform IADLs,
especially being able to shop for personal items (including medications).42 Yet
another study of approximately 300 patients reported that excessive polypharmacy
(using ⬎10 drugs) was associated with a decline in the ability to perform IADLs. Only
30% of patients with no polypharmacy were found to have difficulty performing
Polypharmacy, Reactions, Geriatric Syndromes
IADLs, whereas 74% of those with excessive polypharmacy were found to have
difficulty with IADLs.43 Higher medication use has also been positively associated
with functional decline in patients who have suffered a fall in the previous year.44
Although medication may be used to preserve some functional capacity, providers
should be aware of the association between polypharmacy and functional decline.
Increased Health Service Utilization and Resources
The use of multiple medications leads to increased costs for both the patient and the
health system as a whole. Whereas the proper use of medications may lead to
decreased hospital and emergency room admissions, the use of inappropriate
medications may not only increase patients’ drug costs but cause them to use more
health care services. A retrospective population study in Ireland concluded that
approximately 9% of the total drug-related expenditures were on potentially inappropriate medications.45 Consequences of polypharmacy can also lead to an increase in
health resources as well. A retrospective cohort study of elderly Japanese patients
reported that patients with polypharmacy were at risk of having a potentially
inappropriate medication, which then increased the risk for hospitalization and
outpatient visits and resulted in a 33% increase in medical costs.46
Increased Risk of Geriatric Syndromes
Cognitive impairments
Cognitive impairment, which includes delirium and dementia, occurs commonly in the
elderly. In a review of 42 cohorts of medical inpatients composed of mostly older
adults, the rate of delirium ranged from 11% to 42%.47 Whereas the cause of delirium
is multifactorial, drugs are a common risk factor and may be the precipitating cause
in 12% to 39% of cases.48 Inouye and Charpentier49 reported that the number of
medications (four or more) added the day before a delirium episode was a risk factor
for delirium. Another study of 156 hospitalized older adults found that the number of
medications was an independent risk factor for delirium.50 The most common drugs
associated with delirium are opioids, benzodiazepines, and anticholinergics. Similarly,
drug classes that can exacerbate dementia are benzodiazepines, anticonvulsants,
and anticholinergic drugs such as tricyclic antidepressants.51
Cognitive impairment measured by the Mini-Mental State Examination (MMSE) has
also been found to be negatively associated with polypharmacy. A cohort study of
294 Finnish elders reported that those with polypharmacy were found to have a
decrease of 1.36 points in their MMSE scores. Twenty-two percent of patients with no
polypharmacy were found to have impaired cognition as opposed to 33% and 54%
with polypharmacy and excessive polypharmacy, respectively.43
Falls
Falls are an especially concerning problem in the elderly, causing increased morbidity
and mortality. Unfortunately, many medications are known to increase the risk of falls.
A cross-sectional study in older outpatients found that the number of prescribed
medications was significantly associated with the risk of falls.52 Another study
evaluating risk factors for those who have not fallen compared with those who have
fallen once and those who have experienced multiple falls found that the number of
medications was associated with an increased risk of falls.53 In the Longitudinal Aging
Study Amsterdam, it was found that use of four or more medications was associated
with increased risk of falling as well as increased risk of recurrent falls.54 Other studies
have shown there is an increased risk of falls from polypharmacy for both hospital and
nursing home populations.55
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178
Author and
Year
Setting
N
Intervention
Results
Muir et al,
200463
General medicine inpatient
service in Veterans Affairs
medical center
836
Medication grid provided to
admitting residents that
included all medications and
administration times over 1
week.
Number of medications reduced in
intervention group (⫺0.92)
compared with control (⫹1.65), as
well as the mean number of doses
(⫺2.47 vs ⫹3.83, respectively).
(P⬍.001 for both).
Zarowitz et al,
200564
Outpatient, managed care
6693 (first intervention)
6039 (second
intervention)
Clinical pharmacists reviewed
drug regimens, educated
physicians and patients on
polypharmacy, and worked
with physicians to reduce
polypharmacy.
The rate of polypharmacy reduced by
67.5% after first intervention, from
29.01 to 9.43 events/1000 patients.
After the second intervention, the
polypharmacy rate was reduced by
39%, from 27.99 to 17.07 events/
1000 patients.
Schamder et al,
200423
Inpatient and outpatient
frail elderly veterans
834
Inpatient and outpatient
geriatric evaluation and
management consisting of
geriatrician, nurse, social
worker, and pharmacist.
Geriatric evaluation and management
reduced the number of unnecessary
and inappropriate drugs in
inpatients (P⬍.05), but not in
outpatients.
Hanlon et al,
199665
Outpatient veterans
208
Clinical pharmacist reviewed
regimens and communicated
recommendations in writing
and verbally to primary
physician.
Using the Medication Appropriateness
Index, inappropriate prescribing
significantly decreased in the
intervention group compared with
the control at 3 months (decrease of
24% versus 6%, respectively, P ⫽
.0006). This benefit was sustained at
12 months (decrease 28% vs 5%,
P ⫽ .002). This result included lower
rates of unnecessary medications in
the intervention group based on
descriptive data.
Shah & Hajjar
Table 1
Drug regimen review to reduce polypharmacy
Outpatient veterans
336
Pharmacist pharmacotherapy
consult.
Reduced average number of
prescriptions per patient (2.4).
Fillit et al,
199967
Outpatient Medicare
beneficiaries
5737 surveyed,
2615 (46%)
responded, 1087
went to physician
Elderly Medicare beneficiaries
at risk for polypharmacy
were sent letters by managed
care organization
encouraging them to meet
with their primary physicians
for medication review.
Physicians provided with
guidelines on polypharmacy.
Of the 1087 patients who scheduled a
medication review, 20% reported
having a medication discontinued.
Fick et al,
200468
Medicare and Choice
southeastern managed
care organization
primary care physicians
and patients
355 physicians
Physicians were mailed a listing
of patients who were taking
potentially inappropriate
medications, as defined by
the Beer’s criteria, as well as
alternative recommendations
provided by multiple
independent pharmacists and
geriatricians.
12.5% of potentially inappropriate
medications were discontinued. The
most common discontinued
medications were antihistamines,
analgesics, and muscle relaxants.
Polypharmacy, Reactions, Geriatric Syndromes
Galt, 199866
179
180
Shah & Hajjar
Use of certain medications is also of concern when considering risk factors for falls
in older adults. Psychotropic and cardiovascular medications are of particular
concern because of their association with increased risk of falls.56,57 In a study of over
300 community-dwelling male veterans, the use of a psychotropic medication was
associated with an increased risk of falls (odds ratio [OR] 1.54; 95% confidence
interval [CI] 1.07–2.22). The use of two or more psychotropic medications further
increased the risk of falls in this population (OR 2.37; 95% CI 1.14 – 4.94).58 A
population-based cohort study of over 2000 Swedish patients evaluated the prevalence of polypharmacy before and after reported hip fracture. Interestingly, the use of
five or more medications was seen in 48% percent of the population before they
fractured a hip compared with 88% after the hip fracture. The proportion of patients
taking 10 or more medication as well as those taking three or more psychotropic
medication also increased after hip fracture.59 This trend of increasing polypharmacy
after a traumatic event such as a hip fracture is of concern because the use of multiple
medications puts the patient at risk for the original event. The risk of further events is
likely to increase, and providers should be aware of this trend and the risk that each
type of medication carries with regard to falls.
Urinary incontinence
Urinary incontinence is yet another problem that commonly affects older adults, and
the use of multiple medications can exacerbate the problem. A retrospective study of
128 patients found that approximately 60% of patients with urinary incontinence were
on at least four medications.60 A cross-sectional study found that medications that
cause polyuria, decreased sensory input, and decreased bladder contractility were
associated with the patient’s self-reported urinary incontinence.61
Nutrition
Polypharmacy also puts elders at increased risk of poor nutritional status. A survey
conducted in community-dwelling elders aged 65 and older reported that polypharmacy was associated with poorer nutritional status. Higher medication use was
associated with a decreased intake of soluble and nonsoluble fiber, fat-soluble
vitamins, B vitamins, and minerals and an increased intake of cholesterol, glucose,
and sodium.62 A prospective cohort study found that nutritional assessment measured by the mini-nutritional assessment–short version was also negatively impacted
by polypharmacy. Only 10% of patients with no polypharmacy were found to be either
malnourished or at risk of malnourishment as compared with 50% in those with
excessive polypharmacy.43
CLINICAL APPROACH TO IMPROVING POLYPHARMACY
Drug Regimen Review
Several studies support reviewing drug regimens to reduce polypharmacy.23,63– 68
These studies have been conducted in inpatient and ambulatory settings, with
regimens reviewed by physicians, pharmacists, and/or managed care organizations.
The studies are summarized in Table 1.
Principles for Optimizing Drug Use in the Elderly
Extensive medication histories should be obtained at the initial visit and updated with
each subsequent encounter. Medication histories should include both prescription
and nonprescription medications and any other health-related food or drink the
patient is consuming. Patients and/or their caregivers should be encouraged to bring
in all prescription and over-the-counter (OTC) products with them to each health care
Polypharmacy, Reactions, Geriatric Syndromes
visit. If the patient cannot bring in the actual products, an updated list of all
medications should be kept with the patient to give to all providers so health records
can be kept as up-to-date as possible. Both primary care and specialist providers
need to have inclusive lists as to not create polypharmacy because of incomplete
health care related data. Additional questioning is most likely needed to ascertain all
of the OTC products that a patient takes. Items such as vitamins, supplements, and
OTC items such as antacids may be inadvertently left off medication lists or not be
included with other medications, because patients often perceive these to be without
risk or unimportant for the health care provider to know about. Informing patients or
caregivers of drug interactions with nonprescription agents may be one way to stress
the importance of providing a comprehensive list of medications to all providers.
Once a complete medication list has been obtained, the provider can then
determine if a medication is warranted and if the benefits outweigh the risks for that
drug. All medications should have an indication, and if they do not, an evaluation is
needed to see if the medication is necessary. Discontinuation of unnecessary
medications is reasonable for most drugs, but some may need to be tapered off to
prevent any adverse drug withdrawal events. It is also important to determine if a new
medication is being used to treat the side effects of another medication. Although
sometimes a prescribing cascade is necessary (eg, potassium supplementation in a
patient receiving a diuretic), many times it adds an unnecessary burden to the
patient’s already complicated medication regimen. Existing therapies should also be
evaluated to determine if they need to be continued or if optimization could occur. As
patients age and their health status changes, medications may become ineffective,
more harmful, or require dosage changes to prevent ADRs from occurring. Nonpharmacologic therapy, such as diet and exercise, should be considered whenever
possible. If a medication is determined to be necessary, health care providers need to
consider the medication’s pharmacokinetic and pharmacodynamic properties, side
effect profile, and current hepatic and renal function for accurate dosing. Medication
cost, patient preference, and potential for drug-drug and drug-disease interactions
should also be considered in prescribing. Reasonable therapeutic goals and
monitoring parameters will help guide therapy to prevent unwanted side effects. It
is also wise for health care providers to create their own personal formularies
where they become very familiar with prescribing a few drugs. Simplifying
medication regimens as well as educating patients regarding medications can
improve adherence.69 Adherence may also be improved with the use of generic
medications whenever possible, pill boxes and other adherence tools, and
educating caregivers.
Two techniques, often referred to as SAIL and TIDE, are helpful in remembering
ways to reduce polypharmacy.9 Summarized in Table 2, they refer to the
following:
• Simple: Keep the regimen as simple as possible. Use medications that can be
dosed once or twice a day. Use a medication that can treat multiple indications.
When drug therapy has been titrated to ideal doses, try to combine medications
into single pills to reduce pill burden.
• Adverse effects: Know the potential adverse effects of medications. Choose
medications that have broad therapeutic indices when possible. Identify medications that are treating adverse effects of other medications. Discontinue the
drug that is causing the adverse effect, if possible.
• Indication: Ensure each medication has an indication and a defined, realistic
therapeutic goal.
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Shah & Hajjar
Table 2
SAIL and TIDE techniques to reduce polypharmacy9
Technique
Description
SAIL
Simplify
Simplify drug regimens to reduce pill burden. Use medications that
can be dosed once or twice daily. Use medications that can treat
multiple conditions.
Adverse effects
Be familiar with adverse effects of medications. Choose medications
that have broad therapeutic indices when possible. Discontinue a
medication that is causing an adverse effect when possible.
Indication
Ensure each medication has an indication and a defined, realistic
therapeutic goal.
List
List the name and dose of each medication in the chart and share it
with the patient and/or caregiver.
TIDE
Time
Allow sufficient time to address and discuss medication issues during
each encounter.
Individualize
Apply pharmacokinetic and pharmacodynamic principles to
individualize medication regimens. Consider dose adjustments for
renal and/or hepatic impairment. Start medications at lower doses
than usual and titrate slowly.
Drug interactions
Consider potential drug-drug and drug-disease interactions. Avoid
potentially dangerous interactions, such as those that can increase
the risk for torsades de pointes.
Educate
Educate the patient and caregiver regarding pharmacologic and
nonpharmacologic treatments. Discuss expected medication
effects, potential adverse effects, and monitoring parameters.
• List: Write down the name and dose of each medication in the chart and share
it with the patient.
• Time: Allow sufficient time to address and discuss medication issues.
• Individualize: Apply pharmacokinetic and pharmacodynamic principles to individual patients to select the most appropriate medication and dose. Consider
dose adjustments for the patient’s renal or hepatic function. Medications should
start at lower than usual doses and be titrated slowly, often referred to as “start
low, go slow.”
• Drug-drug and drug-disease interactions: Consider potential drug-drug and
drug-disease interactions, and avoid potentially dangerous interactions such as
those leading to torsades de pointes.
• Educate: Educate the patient and caregiver regarding pharmacologic and
nonpharmacologic treatments. Discuss expected medication effects, potential
adverse effects, and drug-drug interactions and monitoring parameters.
SUMMARY
The elderly are at risk for polypharmacy, which is associated with significant
consequences such as adverse effects, medication nonadherence, drug-drug and
drug-disease interactions, and increased risk of geriatric syndromes. Providers
should evaluate all existing medications at each patient visit for appropriateness and
weigh the risks and benefits of starting new medications to minimize polypharmacy.
Polypharmacy, Reactions, Geriatric Syndromes
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